Healthcare Provider Details

I. General information

NPI: 1952509390
Provider Name (Legal Business Name): JEREMY PETER SIEGRIST M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 CAMELOT DR STE 200
VIRGINIA BEACH VA
23454-2440
US

IV. Provider business mailing address

1800 CAMELOT DR STE 200
VIRGINIA BEACH VA
23454-2440
US

V. Phone/Fax

Practice location:
  • Phone: 757-252-9600
  • Fax: 757-351-2905
Mailing address:
  • Phone: 757-252-9600
  • Fax: 757-351-2905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number0101247001
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101247001
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: